cms_WV: 8204
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8204 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 279 | E | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, staff interview, and observations, the facility failed to ensure care plans reflected the care a resident was assessed to need, and the care that was being provided to the residents. The care plans were not accurate and did not reflect the care being provided to the residents. This was found to be true for nine (9) of forty-six (46) sampled residents. Resident identifiers: #145, #179, #132, #73, #35, #104, #7, #3, and #117. Facility Census: 115. Findings include: a) Resident #145 1) This resident was observed on 05/14/12 at 1:00 p.m. in a bed in the high position. She had her bedside table beside her and appeared comfortable. She was interviewed and was alert and oriented answering all of the questions correctly as verified in her record. She was observed in bed multiple times and always had her head elevated in a high position and not in a low bed. During a review of the physician's orders [REDACTED]. It was verified in the medical record this resident had not fallen since she had been at this facility. She had fallen at home and broken her leg. She had been admitted to the facility for therapy. A nursing assistant (Employee # 46) was interviewed, on 05/17/12 at 12:15 p.m., regarding this resident's bed. She stated she had never seen this resident in a low bed and that she did not know she needed one. She also said she had never seen this resident try to get up and did not know of any falls since the resident had been there. The resident's care plan,dated 04/30/12,was reviewed. The care plan identified this resident as a falls risk. The intervention listed in her care plan was utilize low bed. 2) The resident's care plan was further reviewed for the amount of transfer assistance she required. Her care plan addressed that she needed extensive/total assistance for ADL (activity of daily living) care in bathing, grooming, dressing, bed mobility, transfers, locomotion, toileting, due to left distal femoral fracture. The goal was for her to perform transfers with supervision within ninety (90) days. The interventions gave directions for the amount of assistance to be provided with every area except transfers. During an interview with the resident, on 05/15/12 at 1:00 p.m., she stated right now the only way she was allowed to transfer was with the mechanical lift. She stated she had never transferred without the lift yet, she had to wait until her doctor approved other methods of transfer. At 12:15 p.m. on 05/17/12, Employee #46 verified staff always use a mechanical lift to transfer this resident. The care plan did not include any directions of transferring only with a mechanical lift. Her medical record was reviewed further and it was noted on 04/20/12 that she had a transfer evaluation. The evaluation noted she was to use the mechanical lift and two people to help her transfer. This information was not recorded in her comprehensive care plan. ====== b) Resident #179 During a resident interview, conducted on 05/14/12 at 1:00 p.m., it was identified that this resident was alert and oriented. She was questioned about her oral status and was ask whether she had any pain in her mouth or problem with her dentures. She said she does have pain related to her dentures because they were too loose and she needed new ones. She stated she could hardly eat anything because her dentures have rubbed her gums sore on the bottom because they are too big. She stated she has lost a lot of weight over the past several months. During a review of the medical record for Resident #179, it was noted her oral assessment was conducted on 04/23/12. This assessment indicated she did not have anything wrong with her teeth at that time. Her Minimum Data Set, dated dated [DATE], also indicated there were no oral or dental problems present. The resident was interviewed again on 05/17/12 at 2:00 p.m. She stated her mouth was still sore and she had requested some soup for dinner. She stated her mouth had been hurting for at least two weeks or maybe more. She was questioned about her mouth and stated no one had looked in it, but she knew it was her dentures rubbing her gums because she had lost weight during the last few months and her dentures were too big. She stated she went and talked with the social worker about them but she did not want to get anything done until she talked with her husband because he may want her to use his dentist. She said that she told the Social Worker to just wait for any further interventions until she talks to her husband. During medication pass on 05/17/12, this surveyor observed a nurse, Employee #3, administering medications to this resident. She told him that her mouth was hurting and she would like some soup for dinner. The nurse told her that he would let her doctor know her mouth was hurting and get her something to rinse it out with that may make it feel better. He did not look in her mouth or do any type of oral exam. Employee #3 was interviewed at 5/17/12 4:30 p.m. and he said that he did not know anything about her mouth pain prior to the resident telling him it was hurting. He stated that they usually pass this type of information in report. Resident #179 was interviewed again, on 05/21/12 at 11:45 a.m., about her mouth. She said it was still hurting. There was no evidence in this resident's care plan it had been identified the resident was having any dental issues or needed new dentures. ====== c) Resident # 132 During a resident interview, on 05/22/12 at 2:30 p.m., Resident #132 was asked the question Do you have any chewing or eating problems? The resident stated she does have chewing and eating problems sometimes because she recently had eight (8) teeth pulled and was getting new dentures soon. She stated that she has MS ([MEDICAL CONDITION]) and has muscle spasm sometimes in her throat. The resident's medical record was reviewed and revealed there were no problems identified with her chewing or eating. There was also no evidence found in the medical record this resident had her lower teeth extracted and was getting new dentures. It was noted that on 12/17/11, an oral assessment was completed. This assessment revealed that the condition of her teeth was decayed, broken, and greater than three teeth were missing. A dental consult in the medical record was dated 01/19/12. According to the dentist, the resident had decayed teeth and needed #21, #22, #23, #24, #25, #26, #27, #28, #29 extracted. According to the dentist, she also needed new dentures. During an interview with the Social Worker (Employee # 17) on 05/21/12 at 11:00 a.m. it was confirmed this resident was getting her new dentures that day. She stated the resident had her teeth pulled recently and she had new dentures made. The resident's comprehensive care plan did not reflect this resident was having oral issues, that she recently had her teeth pulled, that she had problems chewing, or that she was getting new dentures. ====== d) Resident #73 It was identified this resident had contractures present to both legs. During a family interview, on 05/22/12, it was identified that the resident does not get up in a chair much anymore due to her contractures and chronic pain. Her last minimum data assessment (MDS), dated [DATE], identified in section S that this resident had contractures to both legs. It was identified this resident had contractures present in 2007 when she was admitted to this facility. The Director of Nursing (DON) was interviewed on 05/21/12 at 10:30 a.m. She verified the contractures of the legs were present when the resident was admitted in 2007. She also verified there were no contractures or interventions identified in the interdisciplinary care plan. The DON provided a procedure that she stated was taught to the nursing assistants about providing basic range of motion. This described the process for providing ROM to residents during care. There were no specific directions provided to the amount of ROM specific for this resident. Her contractures were not included in her care plan and specific positioning instructions were not provided. ====== e) Resident #35 Review of the medical record for Resident #35 found she was receiving hospice services. The resident's care plan contained no evidence the resident was receiving hospice services as the facility failed to incorporate goals and interventions related to hospice services. Further review of the medical record found hospice services had created a care plan for their services. No goals or interventions were developed on the care plan. The hospice care plan only gave the facility instructions to notify hospice. An example: Potential for Injury - Notify Hospice., Bowel - Notify Hospice, Impairment of skin integrity - Notify Hospice. No evidence could be found the hospice care plan identified interventions for the facility staff to follow without first notifying hospice. On 05/21/12 at 1:45 p.m., Employee #2 (director of nursing) confirmed there was an issue with the care plans. ====== f) Resident #104 Review the medical record for Resident #104 discovered the minimum data set assessment, with an assessment reference date (ARD) of 04/26/12, indicated she was on a toileting program for being frequently incontinent. No evidence was found in the care plan related to the resident's incontinence and no interventions were put in place. On 05/21/2 at 1:45 p.m., Employee #2 (director of nursing) confirmed there was an issue with the care plans. ====== g) Resident #7 Review of the medical record found the current care plan, with a target date of 06/09/12, identified the resident received a regular diet with magic cups twice-a-day (bid) to maintain a stabilized weight with no significant changes. Further review found the resident's bid magic cups were discontinued on 02/22/12. An interview with a dietary staff member, on 05/21/12 at 2:30 p.m., revealed Resident #7's diet was downgraded to a mechanical soft diet. The staff member provided a copy of the diet order and communication form, signed by licensed practical nurse (LPN), Employee #67, on 05/09/12. This care plan incorrectly instructed staff to provide magic cups bid and failed to identify the change in the resident's diet consistency. h) Resident #3 Review of the minimum data set (MDS), with an assessment reference date (ARD) of 02/26/12, found this resident had been assessed as having contractures of the neck, both shoulders, both elbows, both wrists, both hips and both ankles. Review of the current care plan, with a target date of 05/27/12, found no goals or interventions to ensure Resident #3 sustained no decline in range of motion. ====== i) Resident #117 Resident #117's medical record, reviewed on 05/21/12 at 1:45 p.m. A staff interview, conducted on 05/02/12 at 3:41 p.m., revealed the resident had slid out of bed on 05/02/12. On 05/21/12, at approximately 2:00 p.m., Employee #19 (minimum data set coordinator) provided a copy of the resident's care plan and a copy of a minimum data set assessment, assessment reference date (ARD) 03/20/12. The resident's MDS revealed the resident triggered for falls. The care area assessment (CAA) summary, dated 03/20/12, revealed the facility would address the care area of falls, which triggered on the MDS. The CAA worksheet for falls indicated the assessment items causing falls to trigger were the anti-anxiety and antidepressant medications the resident had received. The CAA worksheet indicated the facility would address falls in the care plan. A review of the resident's care plan revealed the facility did not include the risk of falls. On 05/21/12, at approximately 1:50 p.m., the director of nursing (DON) Employee #2 became aware the care plan for Resident #117 did not address the resident's risk for falls. She indicated she knew the facility had issues with the development and revision of the resident care plans. | 2016-07-01 |